title: Lung ultrasound for the evaluation of pulmonary congestion in outpatients: a comparison with clinical assessment, natriuretic peptides, and echocardiography.
abstract: OBJECTIVE
  The aim of this study was to define the performance of lung ultrasound (LUS) compared with clinical assessment, natriuretic peptides, and echocardiography, to evaluate decompensation in patients with systolic heart failure (HF) in an outpatient clinic.
  
  
  BACKGROUND
  Evaluation of pulmonary congestion in chronic HF is challenging. LUS has been recently proposed as a reliable tool for the semiquantification of extravascular lung water through assessment of B-lines.
  
  
  METHODS
  This was a cohort study of patients with moderate to severe systolic HF. Receiver-operating characteristic (ROC) analyses were performed to compare LUS with a previously validated clinical congestion score (CCS), amino-terminal portion of B-type natriuretic peptide (NT-proBNP), E/e' ratio, chest x-ray, and 6-min walk test.
  
  
  RESULTS
  Ninety-seven patients were enrolled. Decompensation was present in 57.7% of patients when estimated by CCS, 68% by LUS, 53.6% by NT-proBNP, and 65.3% by E/e' ≥15. The number of B-lines was correlated to NT-proBNP (r = 0.72; p < 0.0001), E/e' (r = 0.68; p < 0.0001), and CCS (r = 0.43; p < 0.0001). In ROC analyses, considering as reference for decompensation a combined method (E/e' ≥ 15 and/or NT-proBNP >1,000 pg/ml), LUS yielded a C-statistic of 0.89 (95% confidence interval: 0.82 to 0.96), providing the best accuracy with a cutoff ≥ 15 B-lines (sensitivity 85%, specificity 83%). A systematic approach using CCS, E/e', NT-proBNP, chest x-ray, and 6-min walk test in different combinations as reference for decompensation also corroborated this cutoff and found a similar accuracy for LUS.
  
  
  CONCLUSIONS
  In an HF outpatient clinic, B-lines were significantly correlated with more established parameters of decompensation. A B-line ≥15 cutoff could be considered for a quick and reliable assessment of decompensation in outpatients with HF.
authors.affiliation: Cardiology Institute of Rio Grande do Sul, Porto Alegre, Brazil. Electronic address: marcelohaertel@gmail.com.
authors.forename: Marcelo Haertel
authors.initials: MH
authors.lastname: Miglioranza
authors.forename: Luna
authors.initials: L
authors.lastname: Gargani
authors.forename: Roberto Tofani
authors.initials: RT
authors.lastname: Sant'Anna
authors.forename: Marciane Maria
authors.initials: MM
authors.lastname: Rover
authors.forename: Vitor Magnus
authors.initials: VM
authors.lastname: Martins
authors.forename: Augusto
authors.initials: A
authors.lastname: Mantovani
authors.forename: Cristina
authors.initials: C
authors.lastname: Weber
authors.forename: Maria Antonieta
authors.initials: MA
authors.lastname: Moraes
authors.forename: Carlos Jader
authors.initials: CJ
authors.lastname: Feldman
authors.forename: Renato Abdala Karam
authors.initials: RA
authors.lastname: Kalil
authors.forename: Rosa
authors.initials: R
authors.lastname: Sicari
authors.forename: Eugenio
authors.initials: E
authors.lastname: Picano
authors.forename: Tiago Luiz Luz
authors.initials: TL
authors.lastname: Leiria
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002908:Chronic Disease; D015331:Cohort Studies; D015150:Echocardiography, Doppler; D005080:Exercise Test; D005260:Female; D054143:Heart Failure, Systolic / Q000097:blood / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010045:Outpatients; D010446:Peptide Fragments / Q000097:blood*; D011237:Predictive Value of Tests; D011379:Prognosis; D011654:Pulmonary Edema / Q000097:blood / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology; D012372:ROC Curve
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain
keywords: 6-min walk test; 6MWT; B-lines; CCS; CXR; E/e′; EVLW; HF; LA; LUS; LV; NT-proBNP; amino-terminal portion of B-type natriuretic peptide; chest x-ray; clinical congestion score; extravascular lung water; heart failure; left atrial; left ventricular; lung ultrasound; natriuretic peptides; pulmonary congestion; ratio of early diastolic mitral inflow velocity to early diastolic velocity of mitral annulus; ultrasound lung comets